Spontaneous intracerebral haemorrhage (ICH) is a devastating cerebrovascular disease with high morbidity and mortality. Branching pattern of the lenticulostriate arteries from the middle cerebral artery makes them susceptible to formation of microaneurysms which have been implicated in hypertensive ICH. Recurrence of haematoma due to delayed development of pseudoaneurysm after initial surgical evacuation is uncommon.
Our patient is a 61 year old gentleman who underwent primary evacuation of a spontaneous right sided ICH. The initial vascular imaging was unremarkable for any underlying vascular malformation. After initial neurological recovery, patient developed another rebleeding in the haematoma cavity nearly 10 days after presentation. A formal angiogram showed the presence of a pseudoaneurysm that was treated via endovascular means.
The rates of rebleeding have ranged from 10-40% in various studies and has been directly correlated with mortality. Since follow up with angiograms is not a usual practice in SICH management, such pseudoaneurysmal rebleeds could go undiagnosed. This case report reinforces the need for a thorough angiographic evaluation in the event of a deviation from expected clinical course, rebleeding not in concordance with intra-operative findings and significantly delayed haematoma recurrence.

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